This study determined the initial investment required for and net financial benefits arising from the implementation of the HIRAID emergency nursing framework at a hospital and State-wide level. The implementation of HIRAID resulted in an estimated cost benefit of $1,914,252 to the study sites with a 75-day payback period. State-wide implementation of HIRAID could save NSW public hospitals $277 million per year as a result of decreased inpatient deterioration. These findings speak strongly in favour of the benefit of HIRAID economically, in addition to its clear patient level benefits.
The implementation of HIRAID required an initial investment, particularly to conduct education and training. This investment was rapidly offset in all three projected scenarios to 2022-23 All health professional education and introduction of interventions within ED come with significant costs, which we have explicitly described in this study. The importance of planning and investment in implementation cannot be understated. There are many instances of less than adequate implementation results in the ED setting where clinician behaviour change is difficult to achieve 19–22. Successful implementation needs appropriate funding, planning and strategies that address the complexity and micro-politics embedded within all health care systems. Implementation strategies need to support individual practitioners, managers, and understand the context as well as receive strong organisational support and patronage which is influential to normalising a new practice among staff 23. An evidence informed and context specific implementation strategy is essential to sustained, reliable and high uptake16,24. While education and training is accompanied by associated cost, this study has shown that HIRAID can lead to significant cost benefits and pay back for an organisation. We recommend the employment of a HIRAID nurse for 18 months to implement, embed and monitor uptake that is tailored for each ED context.
Prevention and early identification of patient deterioration improves outcomes, quality of life and lessens the intervention required to stabilise patients whose condition deteriorates unexpectedly in acute health service organisations2. Several health service wide interventions have been implemented to address the multiple complex organisational and workforce factors that contribute to patient deterioration25. Nonetheless, avoidable patient deterioration rates continue as a result of failure to recognise and rescue. Across the literature recognizing patient deterioration comprises four key areas: (1) assessing the patient; (2) knowing the patient; (3) education and (4) environmental factors26. The HIRAID framework13, and accompanying implementation strategy24 encompasses these areas ensuring emergency nursing staff have the capability, capacity and opportunity to apply HIRAID in their clinical practice.
Future research should include the evaluation of other benefits of improved emergency nursing care, nurse sensitive adverse events and patient deterioration. For example, the reduced LOS that is generated through reduced patient deterioration14 and nurse sensitive adverse events27 may create additional inpatient capacity. This in turn could improve associated key performance indicators such as non-compliance with emergency treatment performance (ETP), which is an independent predictor of all cause 30-day mortality for patients presenting to, and admitted via ED28.
There are limitations to this study. Although all care was taken in the identification and assessment of patient deterioration events and a standardised process used, it is possible some were missed. This study was conducted in one health district, and despite the incidence of patient deterioration and adverse events in all hospitals, the types of incidences may differ, reducing the applicability to other hospitals. Cost estimates are likely to differ between countries, institutions and populations, thus potentially limiting the generalisability of this and all cost-effectiveness studies in health education29.